IPPS Proposed Rule Detailed

Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions: acute myocardial infarction (i.e., heart attack), heart failure, and pneumonia. CMS also finalized its definition of readmission as "occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization."

In the FY 2013 IPPS proposed rule, CMS proposes to codify the definition of "excess readmission ratio" as a:

…hospital-specific ratio for each applicable condition for an applicable period, which is the ratio (but not less than 1.0) of (1) risk-adjusted readmissions based on actual readmissions for an applicable hospital for each applicable condition to (2) the risk-adjusted expected readmissions for the applicable hospital for the applicable condition.

In addition, CMS proposes defining "base operating DRG payment amount" under the Readmissions Reduction Program as the wage-adjusted DRG operating payment plus any applicable new technology add-on payments. CMS also proposes to exclude the difference between the hospital's applicable hospital-specific payment rate and the federal payment rate from the definition of "base operating DRG payment amount."

CMS also addresses these areas related to the program:

Adjustment factor (both the ratio and floor adjustment factor)

Aggregate payments for excess readmissions and aggregate payments for all discharges

Applicable hospital

Limitations on review

Reporting of hospital-specific information, including the process for hospitals to review and submit corrections

Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013: surgical site infection following cardiac implantable electronic device (CIED) and iatrogenic pneumothorax with venous catheterization.

Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS also plans to add two codes, 999.32 (bloodstream infection due to central catheter) and 999.33 (local infection due to central venous catheter) to the existing vascular catheter-associated infection HAC category.

With these additions, there was no need for new codes. CMS just states that the combination of these diagnosis and procedure codes would be identified as a HAC, McCall says.

This is not the first time CMS has proposed to add pneumothorax to the HAC list. CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says.